The Basics Behind Efficient Organizations
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Quality & The role for shift patterns
C-DESK
Quality of a Service Provider
Articles on Creating Shift Patterns
Introduction
Quality comes in many forms. This article concentrates on one very important aspect of quality, how staffing levels are seen to affect the quality from the recipients point of view.
The Quality of a service provider is in the eye of the beholder. Therefore, the most important aspect of quality is to provide a consistent level of service. A balanced level of service. Service enterprises are not readily comparable between themselves, only against itself. It is so difficult to move from one service provider to another as a client that it isn't done except as a last resort. So, the client (and other related parties) can only judge the quality of service of the provider by comparing it against itself. In practise, this means comparing the service on one shift against the next shift. Excellent service is judged as being no variation, poor service is when there is a variation which oscillates from one day to the next.
Variations in service are judged on the following points;
Number of staff on duty.
Skills mix of staff on duty.
Experience of staff on duty.
How the clients treatment varies.
How the problem issues of the client varies.
Providing more staff is not the best solution, providing equality of service is. If the quality of service given does not vary, it is impossible to judge quantitatively the quality. If the level of service is better, or worse, than the company next door, how will anyone know? Any change in quality over a long time period is impossible to detect, but shorten the time period to days or hours and it is very apparent.
Quality viewed from the clients point of view is very different from the quality viewed by the staff. Staff can only view the quality of their shift, or based on second hand information, the quality on previous shifts. Quality during a shift is usually equal throughout the shift, since it is the same people and in general they can be expected to perform in a consistent manner and give a level of service to the best of their ability.
Quality comes in many forms. This article concentrates on one very important aspect of quality, how staffing levels are seen to affect the quality from the recipients point of view.
The Quality of a service provider is in the eye of the beholder. Therefore, the most important aspect of quality is to provide a consistent level of service. A balanced level of service. Service enterprises are not readily comparable between themselves, only against itself. It is so difficult to move from one service provider to another as a client that it isn't done except as a last resort. So, the client (and other related parties) can only judge the quality of service of the provider by comparing it against itself. In practise, this means comparing the service on one shift against the next shift. Excellent service is judged as being no variation, poor service is when there is a variation which oscillates from one day to the next.
Variations in service are judged on the following points;
Number of staff on duty.
Skills mix of staff on duty.
Experience of staff on duty.
How the clients treatment varies.
How the problem issues of the client varies.
Providing more staff is not the best solution, providing equality of service is. If the quality of service given does not vary, it is impossible to judge quantitatively the quality. If the level of service is better, or worse, than the company next door, how will anyone know? Any change in quality over a long time period is impossible to detect, but shorten the time period to days or hours and it is very apparent.
Quality viewed from the clients point of view is very different from the quality viewed by the staff. Staff can only view the quality of their shift, or based on second hand information, the quality on previous shifts. Quality during a shift is usually equal throughout the shift, since it is the same people and in general they can be expected to perform in a consistent manner and give a level of service to the best of their ability.
Does your staffing vary from day to day? Want to know why?
300
Shift
Patterns
in one
book
There are 2 times of day at which quality is most easily judged. At the shift change-over time and the same shift on consecutive days, when changes are inevitable and noticeable. A usual comparison is to use time. Such as, what happened at the same time the previous day, or how long a typical and repetitive task took to do. Another test is 'how nice someone is'. Another test is how well a repetitive task is done and by whom and what grade of staff.
All establishments have a structured hierarchy or seemingly individual elements. A typical one for a Nursing Home is (Hospitals will involve more types of staff, such as Doctors, X-ray, physio, etc but these are generally one off events of a stay and not easily comparable)
Head nurse
Administrator
Trained Nurses (RGN SEN in Britain)
Care Assistants
Catering
Cleaning
Laundry
Maintenance
Some of these can be sub-divided; i.e. Day staff and Night Staff, or amalgamated. A structure such as this can give efficiencies. Training is minimised to one skill only, and tasks can be skilfully completed routinely. The disadvantage is an almost perpetual quality problem caused by the above hierarchy and elements(tasks) not being separated in practise. Instead they are a team and tasks are continually passed from one element to another. All tasks involve an interaction between 2 or more elements, and the majority of the tasks have to be completed sequentially in real time, totally different to industry where the system was invented and which uses the system to produce batches of goods. For example, beds cannot be changed if a patient hasn't been got up and the laundry hasn't any clean bedding, patients cannot have medicines after a meal if the meal hasn't been served, and so on. The key phrase in all these tasks is the word 'hasn't', meaning that something had to be completed in the past before the current task can take place.
HOW 99% ATTENDANCE OR 101% ATTENDANCE CAN BE A QUALITY PROBLEM
Imagine your own structure, a typical mid-week daytime shift might be something like(Title followed by number of staff on duty)
MORNING PERIOD
Head Nurse 1
Administrator 1
Trained staff RGN SEN 2
Care Assistants 6
Catering 3
Cleaning 2
Laundry 1
Maintenance 1
total staff on duty = 17
AFTERNOON PERIOD
Head Nurse 1
Administrator 1
Trained staff RGN SEN 2
Care Assistants 6
Catering 3
Cleaning 2
Laundry 1
Maintenance 1
total staff on duty = 17
EVENING PERIOD
Head Nurse 0
Administrator 0
Trained staff RGN SEN 1
Care Assistants 6
Catering 0
Cleaning 1
Laundry 0
Maintenance 0
total staff on duty = 8
Assuming that all staff cover 2 of the time periods, then a total of 25 different staff should work during the day. Plus probably another 4 staff on night duty, making 29 in all. If everyone shows up on time, and works well during their shift, then everything is just as it should be and barring emergencies, the quality of the care will be good. The problem with this system is when one person does not come in and a replacement cannot be found to cover the person's shift. Unfortunately the above system means that if one person is off in the morning, then it is not seen as a reduction of the workforce from 17 to 16. Instead it hits the element of work. For instance, Care Assistants are reduced from 6 to 5, a reduction of 17%, catering from 3 to 2, a reduction of 33%, or laundry from 1 to 0, a reduction of 100%. This creates a bottleneck and slows the whole process down and puts pressure on everyone. After all, each days tasks are the same, take the same time, and happen at the same time of day. Hence, when one person is absent, the routine is destroyed, and everyone has to work around the new time schedule caused by the bottleneck. This involves learning a new procedure just for that one day, and then returning to the usual procedure the next day. People take time to learn new schedules and methods and are not keen on make-do and having to change their routine. Most of the tasks cannot be put off for another day, as in commerce, they just have to be done.
Hence, we have a situation where the absence of one person in a day can cause severe problems. One person absent out of 29 that should have been at work that day means an attendance record of 97%, excellent in commerce terms. In caring, the absence of one person can cause problems way out of proportion to the numbers involved. Assuming this happens every other day, we are talking about a 99% attendance record causing quality problems, because patients notice when things aren't done or completed from one day to the next.
The opposite side of the coin is when extra staff are on duty in addition to the usual numbers above. Too many staff can cause severe quality problems. If an extra person is on in the morning, the staff workforce has increased from 17 to 18. However, the extra person will be in one of the elements and hence Care Assistants might be increased from 6 to 7, an increase of 17%, or catering might be increased from 3 to 4, an increase of 33%, or laundry increases from 1 to 2, an increase of 100%. On the surface, this might appear to be a method of improving quality, far from it. Now, instead of one bottleneck being created, every element, other than the one which has more staff, becomes a bottleneck. For instance, more Care Assistants in the morning means that the patients are up and ready for breakfast earlier, but catering is still working at the usual rate, so all the patients are waiting longer than usual, which is a bad start to the day. It does not get better when the patients find themselves waiting time and again throughout the day. This is not perceived as a better quality of service. A variable level of service is seen as inferior to an average level of service, because it shows what could be done if enough resources were poured into the system.
The only solution is to have the right number of staff on duty every day and to make sure that it is the same number every day. This is one reason why so much effort is expended in having reliable staff and if someone cannot do their shift, to try and replace them.
Is there a Solution to this Type of Quality Problem?
Having explained why there is a quality problem, it does produce a quick fix solution. Change your routine so that it varies every day and then there isn't a time framework for patients to set their clocks by. Having different events each morning, which start and finish at different times gives just the right excuse to cover most staffing problems. ie. Monday = craft class, Tuesday = movement to music, Wednesday = church service, and so on. Another excuse is to use the weather to change the routine. Fortunately, in Britain, every day's weather is different and it makes for a great excuse.
Long term solutions to quality problems has to involve changing the way the staff are employed. The staff have to be flexible in their job descriptions and they have to be trained in those tasks which are additional to their normal work. The staff have to be flexible in working, on average, their contractual hours each week, rather than having an exact number of hours each week. This involves having a computer program capable of planning the schedule months in advance.
All establishments have a structured hierarchy or seemingly individual elements. A typical one for a Nursing Home is (Hospitals will involve more types of staff, such as Doctors, X-ray, physio, etc but these are generally one off events of a stay and not easily comparable)
Head nurse
Administrator
Trained Nurses (RGN SEN in Britain)
Care Assistants
Catering
Cleaning
Laundry
Maintenance
Some of these can be sub-divided; i.e. Day staff and Night Staff, or amalgamated. A structure such as this can give efficiencies. Training is minimised to one skill only, and tasks can be skilfully completed routinely. The disadvantage is an almost perpetual quality problem caused by the above hierarchy and elements(tasks) not being separated in practise. Instead they are a team and tasks are continually passed from one element to another. All tasks involve an interaction between 2 or more elements, and the majority of the tasks have to be completed sequentially in real time, totally different to industry where the system was invented and which uses the system to produce batches of goods. For example, beds cannot be changed if a patient hasn't been got up and the laundry hasn't any clean bedding, patients cannot have medicines after a meal if the meal hasn't been served, and so on. The key phrase in all these tasks is the word 'hasn't', meaning that something had to be completed in the past before the current task can take place.
HOW 99% ATTENDANCE OR 101% ATTENDANCE CAN BE A QUALITY PROBLEM
Imagine your own structure, a typical mid-week daytime shift might be something like(Title followed by number of staff on duty)
MORNING PERIOD
Head Nurse 1
Administrator 1
Trained staff RGN SEN 2
Care Assistants 6
Catering 3
Cleaning 2
Laundry 1
Maintenance 1
total staff on duty = 17
AFTERNOON PERIOD
Head Nurse 1
Administrator 1
Trained staff RGN SEN 2
Care Assistants 6
Catering 3
Cleaning 2
Laundry 1
Maintenance 1
total staff on duty = 17
EVENING PERIOD
Head Nurse 0
Administrator 0
Trained staff RGN SEN 1
Care Assistants 6
Catering 0
Cleaning 1
Laundry 0
Maintenance 0
total staff on duty = 8
Assuming that all staff cover 2 of the time periods, then a total of 25 different staff should work during the day. Plus probably another 4 staff on night duty, making 29 in all. If everyone shows up on time, and works well during their shift, then everything is just as it should be and barring emergencies, the quality of the care will be good. The problem with this system is when one person does not come in and a replacement cannot be found to cover the person's shift. Unfortunately the above system means that if one person is off in the morning, then it is not seen as a reduction of the workforce from 17 to 16. Instead it hits the element of work. For instance, Care Assistants are reduced from 6 to 5, a reduction of 17%, catering from 3 to 2, a reduction of 33%, or laundry from 1 to 0, a reduction of 100%. This creates a bottleneck and slows the whole process down and puts pressure on everyone. After all, each days tasks are the same, take the same time, and happen at the same time of day. Hence, when one person is absent, the routine is destroyed, and everyone has to work around the new time schedule caused by the bottleneck. This involves learning a new procedure just for that one day, and then returning to the usual procedure the next day. People take time to learn new schedules and methods and are not keen on make-do and having to change their routine. Most of the tasks cannot be put off for another day, as in commerce, they just have to be done.
Hence, we have a situation where the absence of one person in a day can cause severe problems. One person absent out of 29 that should have been at work that day means an attendance record of 97%, excellent in commerce terms. In caring, the absence of one person can cause problems way out of proportion to the numbers involved. Assuming this happens every other day, we are talking about a 99% attendance record causing quality problems, because patients notice when things aren't done or completed from one day to the next.
The opposite side of the coin is when extra staff are on duty in addition to the usual numbers above. Too many staff can cause severe quality problems. If an extra person is on in the morning, the staff workforce has increased from 17 to 18. However, the extra person will be in one of the elements and hence Care Assistants might be increased from 6 to 7, an increase of 17%, or catering might be increased from 3 to 4, an increase of 33%, or laundry increases from 1 to 2, an increase of 100%. On the surface, this might appear to be a method of improving quality, far from it. Now, instead of one bottleneck being created, every element, other than the one which has more staff, becomes a bottleneck. For instance, more Care Assistants in the morning means that the patients are up and ready for breakfast earlier, but catering is still working at the usual rate, so all the patients are waiting longer than usual, which is a bad start to the day. It does not get better when the patients find themselves waiting time and again throughout the day. This is not perceived as a better quality of service. A variable level of service is seen as inferior to an average level of service, because it shows what could be done if enough resources were poured into the system.
The only solution is to have the right number of staff on duty every day and to make sure that it is the same number every day. This is one reason why so much effort is expended in having reliable staff and if someone cannot do their shift, to try and replace them.
Is there a Solution to this Type of Quality Problem?
Having explained why there is a quality problem, it does produce a quick fix solution. Change your routine so that it varies every day and then there isn't a time framework for patients to set their clocks by. Having different events each morning, which start and finish at different times gives just the right excuse to cover most staffing problems. ie. Monday = craft class, Tuesday = movement to music, Wednesday = church service, and so on. Another excuse is to use the weather to change the routine. Fortunately, in Britain, every day's weather is different and it makes for a great excuse.
Long term solutions to quality problems has to involve changing the way the staff are employed. The staff have to be flexible in their job descriptions and they have to be trained in those tasks which are additional to their normal work. The staff have to be flexible in working, on average, their contractual hours each week, rather than having an exact number of hours each week. This involves having a computer program capable of planning the schedule months in advance.
Staff Structure
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Merton Borough Council
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Babtie
Merton Borough Council
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